complaint·March 20, 2023

On 12/21/2022, LPA Camara conduct an intial complaint investigation visit to the facility and conducted a brief tour of the facility at 2:45 p.m. LPA conducted records review at 2:55 p.m. and obtained copies of pertinent documents. LPA conducted interviews with staff and residents between 3:05 p.m. and 4:15 p.m. On 3/15/2023, LPA conducted a telephone interview with former staff. On 3/17/2023, LPA conducted a telephone interview with a witness. Facility records showed R1 was receiving hospice care. On 12/21/2022, LPA had attempted to speak with R1, however R1's condition prevented a successful interview. LPA observed R1 was on the couch watching television with other residents. R1 would frequently scream as if in distress and would frequently yell "ouch" although nobody was near them. Staff would sit with R1 to provide comfort. During an interview with another resident, resident 2 (R2), they indicated staff at the faciltiy provide excellent care and they are very caring and patient with R1. R2 had no concerns about the care provided at the facility. During interviews with staff, they stated on the date of the accident, 12/10/2022, R1 required incontinence care so two staff took R1 into the bathroom to get cleaned up. One staff left the bathroom to attend to another resident and during that time R1 fell forward off of the toilet and hit their forehead on the handrail directly across from the toilet. Staff was able to get R1 back on the toilet. Staff stated R1 had a bump on their head and bruising. The bruising eventually made its way down to R1's eyes and then down R1's face. The administrator and licensee stated they consulted with a hospice nurse regarding the bruising since it was concerning that the bruising traveled down R1's face but the hospice nurse told them it was normal for that type of injury. LPA interviewed a hospice nurse who confirmed the bruising process was normal for that type of injury. The nurse stated they did not realize facility staff cleaned R1 in the bathroom until after the incident and they understood the mechanism of injury. Based on the information obtained during interviews and document reviews, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation "Resident sustained questionable injury while in care" is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report was provided to the administrator.